Oakley, J. (2003). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.



On January 2, 2013 at 5:34 am, the maintenance technician noticed a leak in the water pipe in the valve department. The valve has had a leak for four months, but because a maintenance request has not been submitted, the problem was not fixed. The maintenance technician was to about to clock out at 5:40 am and decided to leave a note for the first shift technician to mop up the area.


At 5:53 am, an air horn was sounded for everyone to respond to an area. As workers arrived, they noted “Bob” lying in a pool of water. It was very obvious to everyone that Bob’s leg was broken. An ambulance was called, and Bob was transported to the hospital. During the investigation, it was learned that the night maintenance technician had noted the water but decided to not clean the area immediately. The night maintenance technician left a note at the desk at 5:41 am and left.


The morning maintenance technician was supposed to clock in at 5:40 am but had called his supervisor at 5:33 am to say that he was running late and would be there by 6 am. He also called and left a message for the morning maintenance technician saying that he was running 15 minutes late. The morning maintenance technician arrived at 5:53 am, heard the alert horns, and responded to the accident.


Using one of the charts on Exhibit 7.1 and 7.6 in your textbook as examples, create an Events and Causal Factors Analysis Timeline of this incident.


Useful hints: You are welcome to choose your own format; you may use PowerPoint, draw the chart by hand and scan it as a PDF, or use some other means. You could use your computer’s paint application, for instance, or use Microsoft Word, and use parentheses for events (Event), square brackets for conditions [Conditions], and brackets for the accident [Accident], or some similar convention (such as color coding text). Whatever convention you choose to use, make sure you provide a key.


Your chart will be graded on content, effort, and presentation. Also, keep in mind that if your chart is difficult to follow, you will lose points. It is expected that you use considerable effort on making your chart easy to understand and navigate.  Also, keep in mind that this assignment is graded with a heavier weight than your standard unit assignments. Your chart may be abbreviated; that is, it does not have to be infinitely detailed, but the key sequence of events should be charted, as should the key conditions surrounding the event. The objective of this project is to provide you with an opportunity to practice with this important and very practical analytical tool.